Print this page Email this page | Users Online: 357
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2017  |  Volume : 8  |  Issue : 4  |  Page : 167-170

Demystifying early carious lesion: A review

1 Department of Conservative Dentistry, Faculty of Dentistry, Melaka Manipal Medical College, Manipal University, Manipal, India
2 Department of Conservative Dentistry and Endodontics, V S Dental College, Bangalore, Karnataka, India
3 Public Health Dentistry, Clinician and Researcher, Smile Recovery Multispecialty Dental Care, Raipur, Chhattisgarh, India

Date of Web Publication14-Dec-2017

Correspondence Address:
Ravi Gupta
Department of Conservative Dentistry, Faculty of Dentistry, Melaka Manipal Medical College, Manipal University, Manipal, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_59_17

Rights and Permissions

Dental caries is a common disease affecting teeth present in the oral cavity. Dental caries is a disease process resulting in the dissolution of dental hard tissue like enamel and dentin. There has been a change in concept from GV Black's “extension for prevention” to a minimal intervention approach in the recent time. Accurate and reliable detection of early enamel caries is very crucial. The new diagnostic methods and remineralization approach would enable the dentist to detect and diagnose early and direct appropriate preventive measures to promote conservation of the tooth substance. These preventive strategies are much more efficient. The aim of Minimal dentistry is to manage early carious lesion by remineralization. The objective of writing this review on early carious lesion is to understand the early caries disease process and its clinical stages, identification of early caries before there is evidence of surface cavitation through various new technologies and allowing remineralization of such lesion.

Keywords: Demineralization, early carious lesion, remineralization agents, remineralization, white spot

How to cite this article:
Gupta R, Kumari AR, Sharma H, Jain L. Demystifying early carious lesion: A review. SRM J Res Dent Sci 2017;8:167-70

How to cite this URL:
Gupta R, Kumari AR, Sharma H, Jain L. Demystifying early carious lesion: A review. SRM J Res Dent Sci [serial online] 2017 [cited 2023 Jun 3];8:167-70. Available from:

  Introduction Top

Enamel is most susceptible to dental caries due to bacterial accumulation and acid attack. Dental caries is a dynamic process due to disturbance between demineralization and remineralization activity.[1]

The main agents responsible are frequent ingestion of fermentable carbohydrates, reduction in salivary function, and increase acidogenic flora. It occurs when acidogenic bacteria in dental plaque – mainly Streptococcus mutans and  Lactobacillus acidophilus Scientific Name Search 211; ferment carbohydrate in the diet-producing lactic acid. These acids result in the dissolution of the mineral content of tooth and initiate the carious process.[2]

Early enamel caries lesion appears as a white opaque spot and is characterized by being softer than the adjacent sound enamel.[3] The early carious lesion is a defect with a relatively intact surface layer, and subsurface changes occur due to acid which is accumulated on the tooth surface.[3] The initial stages of the carious lesion are characterized by a partial dissolution of tissue called “white spot lesions.”

Bishara et al., 2008, defined white spot lesions as the subsurface porosity of demineralized enamel that manifests itself as milky white opacities localized on smooth surfaces. This defect has a low mineral content as a result of which the surface layer is porous as compared to sound enamel.[4] Enamel demineralization is characterized by the removal of soluble magnesium and carbonate mineral content. This allows acids from plaque to penetrate the surface and attack the subsurface and leading to white spot or early carious lesion.

Early caries lesions are also known as incipient lesions and “surface-softened defect” or white spot lesion. The differentiation of early carious lesion from arrested lesions is important. “Microscars” were seen on active progressing carious lesion.[5]

The early carious lesion is known to be reversible in nature and can remineralize when treated with proper preventive and remineralization approach.[6] Early detection and diagnosis play a major role to halt the progress of the disease process.

  Clinical Characteristics of Early Carious Lesions Top

  1. On drying with air using a three-way syringe, incipient lesion appears as a chalky white spot on the enamel surface. This is due to difference in refractive index of sound enamel, water, and air which is 1.62, 1.33, and 1.0, respectively. Initial demineralization during caries attack makes the enamel porous; these microporosities of surface enamel are filled with a watery medium, i.e. saliva who's refractive index is almost similar to water. However, when tooth is dried or desiccated, saliva filled in these microporosities is replaced by air who's refractive index is 1.0. This difference in refractive indices between the enamel crystals and medium inside the porosities causes scattering of light in different angles as a result affected enamel appears whitish opaque or chalky white with loss of enamel translucency when dehydrated [7],[8]
  2. Similarly, when rehydrated chalky white incipient lesions disappear due to replacement of air in microporosities with saliva [7],[8]
  3. The enamel surface is porous in nature [7]
  4. Active lesions are seen in plaque stagnation areas and close to the gingival margin
  5. The surface layer being porous is susceptible to damage by probing, especially in pits and fissures.[7]

  Sites of Occurrence of Early Carious Lesion Top

Most common site is cervical third of a tooth, especially patients with prosthodontic restorations and patients who are undergoing orthodontic treatment.[9],[10]

  Benefits of Early Carious Lesion Detection Top

Benefits are:

  • Ability to “remineralize” noncavitated tooth surfaces [9]
  • Decrease progression of the carious process
  • Reduced tooth sensitivity associated with the deeper lesion [9]
  • Preservation of natural esthetic and function of the tooth
  • Reduced treatment cost and conservation of tooth structure.[11]

  Diagnosis and Detection of Early Carious Lesion Top

Diagnosis of the early carious lesion is important and preventive measures can be used to control disease progress. Old methods of detecting early lesions include visual and clinical examination and radiographs. However, these methods are not accurate in the assessment of early carious lesion and may give false-negative results.

Radiographs fail to detect early carious lesion because 30%–40% mineral loss is required so that lesion can be seen radiographically. It takes a long time for demineralization to be visible on radiograph which makes diagnosis much more difficult.[12]

Old diagnostic methods are not reliable for early carious lesion detection since they lack sufficient reliability.

At present, many new diagnostic modalities have been introduced in market such as digital imaging fiber-optic transillumination, optical coherence tomography, laser fluorescence, electronic caries meter, Raman spectroscopy, and Terahertz imaging which makes the process of diagnosis of early carious lesion much more accurate and easier.[13],[14]

  Management Top

Education and motivation of patient

It is important to educate patient regarding early carious lesion and motivation to maintain proper oral hygiene so that these lesions can be prevented.

Mechanical/chemical plaque control

Mechanical methods of caries prevention include oral hygiene procedures such as proper tooth brushing, use of floss and interdental cleaning aids, and professional oral prophylaxis.[11]

The mouthwashes containing antimicrobial agents such as chlorhexidine, triclosan, and cetylpyridinium chloride and tooth paste containing anticariogenic and remineralizing agents such as flouride and CCP-ACP.

These toothpaste are proved to be highly effective in reversing incipient caries. These strategies are highly effective in arresting and reversing early carious in lesions in high-risk people.

Remineralizing agents

These are the agents which are commonly used to manage early carious lesions or white spot lesion through a remineralization approach. They increase oral calcium and phosphate levels and shifts the equilibrium toward remineralization.

Apart from white spot lesion management, they are also used in patients undergoing orthodontic treatment and bleaching procedure to reduce decalcification risk.

  Various Remineralizing Agents Top


The anticaries effect of fluorides is known since a long time. It increases the resistance of enamel to caries by increasing rate of enamel maturation and alteration in tooth morphology. Moreover, it also inhibits enzyme enolase and thus enhances remineralization.[15]

Casein phosphopeptide-amorphous calcium phosphate

It is discovered and patented by Eric Reynolds and coworkers at the University of Melbourne in 2002. It is protein nanotechnology which involves the use of specific phosphoproteins from bovine milk and combines it with nanoparticles of ACP.

It acts by localizing ACP at the tooth surface, which buffers the free calcium and phosphate ions and forms a supersaturated solution of these ions enhancing remineralization.[16] GC Tooth Mousse is used in cases of enamel lesions and white spot lesions.

Tricalcium phosphate (Clinpro Tooth creme)

During brushing when TCP paste comes in contact with saliva, it causes the release of Ca, P, and F ions and thus brings about the process of mineralization.[17]


It is based on bioactive glass technology. On contact with saliva, it rapidly releases sodium ions which raise the local Ph and causes the release of Ca and P.[18],[19]


Based on the ACP technology, in which ACP was incorporated into toothpaste to bring about the process of remineralization.[20]


It is a sugar substitute which shows anticariogenic as well as cariostatic action. It inhibits the growth of S. mutans. Xylitol also stimulates increases salivary flow which reduce the risk of caries and promote remineralization.[21],[22]

Sensistat technology

Based on arginine technology, in which arginine bicarbonate, amino acid, and calcium carbonate particle are incorporated in toothpaste. This arginine compound holds calcium carbonate particles on the tooth surface as a result of which calcium carbonate dissolves slowly and release calcium which results in tooth remineralization.[23]

Grape seed extract

Enzyme glucosyltransferases are inhibited by Proanthocyanidin (PA) present in grape seed extract which in turn inhibits caries. Grape seed extract is a promising agent in future, but further studies are required to establish its role.[24]


Recent studies have shown that a concentration of 10% nanohydroxyapatite crystals can result in remineralization and can be used for the management of early carious lesion in the future.[25]

  Resin Infiltration Method Top

It is a new method which involves infiltration of resin into the porous enamel of early carious lesions, thereby preventing the disease progression.[26] It is a noninvasive method which is safe and simple. Marketed as ICON caries infiltrant. Hence this new method is beneficial in management of various problems like white spot lesions, amelogensisis imperfecta, and molar incisor hypomineralization.

Belli et al. concluded that this method improves surface stability and reduces the risk of early carious lesion.[27]

  Conclusion Top

The dentist should diagnose and treat noncavitated early carious lesions with the help of new diagnostic methods with an emphasis on remineralization and prevention rather than restoration.

The current change in the approach to dental caries and the popularity of minimally invasive dentistry and preventive dentistry have resulted in an increased demand for materials to remineralize the tooth structure.

These agents are an adjunct to preventive dentistry and research is going on to find a suitable remineralizing agent that can result in complete reversal of the carious process and complete remineralization of the enamel and dentin.

There are no conflicts of interest.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Featherstone JD. The continuum of dental caries – Evidence for a dynamic disease process. J Dent Res 2004;83:C39-42.  Back to cited text no. 1
Barbería E, Maroto M, Arenas M, Silva CC. A clinical study of caries diagnosis with a laser fluorescence system. J Am Dent Assoc 2008;139:572-9.  Back to cited text no. 2
Roopa KB, Pathak S, Poornima P, Neena IE. White spot lesions: A literature review. J Pediatr Dent 2015;3:1-7.  Back to cited text no. 3
  [Full text]  
Joshi S, Joshi C. Management of enamel white spot lesions. J Contemp Dent 2013;3:133-7.  Back to cited text no. 4
Arends J, Christoffersen J. The nature of early caries lesions in enamel. J Dent Res 1986;65:2-11.  Back to cited text no. 5
Ferreira Z, Zero DT. Diagnostic tool for early caries detection. J Den Res 2004;83(Suppl 1):c84-8.  Back to cited text no. 6
Mount GJ. Defining, classifying, and placing incipient caries lesions in perspective. Dent Clin North Am 2005;49:701-23, v.  Back to cited text no. 7
Gugnani N, Pandit IK, Gupta M, Josan R. Caries infiltration of noncavitated white spot lesions: A novel approach for immediate esthetic improvement. Contemp Clin Dent 2012;3:S199-202.  Back to cited text no. 8
Machale PS, Hegde-Shetiya S, Agarwal D. The incipient caries. J Contemp Dent 2013;3:20-4.  Back to cited text no. 9
Artun J, Brobakken BO. Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod 1986;8:229-34.  Back to cited text no. 10
Fejerskov O, Edwina AM. Kidd caries epidemiology, with special emphasis on diagnostic standards. In: Dental Caries: The Disease and its Clinical Management. Denmark: Gray publishing, Blackwell Munskgaard; 2003. p. 141-61.  Back to cited text no. 11
Ferreira RI, Haiter-Neto F, Tabchoury CP, de Paiva GA, Bóscolo FN. Assessment of enamel demineralization using conventional, digital, and digitized radiography. Braz Oral Res 2006;20:114-9.  Back to cited text no. 12
Hall A, Girkin JM. A review of potential new diagnostic modalities for caries lesions. J Dent Res 2004;83:C89-94.  Back to cited text no. 13
Fried D, Featherstone JD, Darling CL, Jones RS, Ngaotheppitak P, Bühler CM, et al. Early caries imaging and monitoring with near-infrared light. Dent Clin North Am 2005;49:771-93, vi.  Back to cited text no. 14
Mellberg RJ, Ripa WL, Leske SG. Fluoride in Preventive Dentistry: Theory and Clinical Applications. Chicago: Quintessence Publishing Co., Inc.; 1983.  Back to cited text no. 15
Reynolds EC. Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J Dent Res 1997;76:1587-95.  Back to cited text no. 16
Karlinsey RL, Mackey AC, Walker ER, Frederick KE. Preparation, characterization and in vitro efficacy of an acid-modified beta-TCP material for dental hard-tissue remineralization. Acta Biomater 2010;6:969-78.  Back to cited text no. 17
Du M, Tai BJ, Jiang H, Zhong J, Greenspan D, Clark A. Efficacyof dentifrice containing bioactive glass (NovaMin) on dentine hypersensitivity. J Dent Res 2004;83:13-5.  Back to cited text no. 18
Burwell A, Jennings D, Muscle D, Greenspan DC. NovaMin and dentin hypersensitivity –in vitro evidence of efficacy. J Clin Dent 2010;21:66-71.  Back to cited text no. 19
Tung MS, Eichmiller FC. Dental applications of amorphous calcium phosphates. J Clin Dent 1999;10:1-6.  Back to cited text no. 20
Hayes C. The effect of non-cariogenic sweeteners on the prevention of dental caries: A review of the evidence. J Dent Educ 2001;65:1106-9.  Back to cited text no. 21
Miake Y, Saeki Y, Takahashi M, Yanagisawa T. Remineralization effects of xylitol on demineralized enamel. J Electron Microsc (Tokyo) 2003;52:471-6.  Back to cited text no. 22
Nizel AE, Harris RS. The effects of phosphates on experimental dental caries: A literature review. Journal of Dental Research 43(Suppl 6):1123-36.  Back to cited text no. 23
Xie Q, Bedran-Russo AK, Wu CD.In vitro remineralization effects of grape seed extract on artificial root caries. J Dent 2008;36:900-6.  Back to cited text no. 24
Huang SB, Gao SS, Yu HY. Effect of nano-hydroxyapatite concentration on remineralization of initial enamel lesion in vitro. Biomed Mater 2009;4:034104.  Back to cited text no. 25
Paris S, Meyer-Lueckel H, Cölfen H, Kielbassa AM. Resin infiltration of artificial enamel caries lesions with experimental light curing resins. Dent Mater J 2007;26:582-8.  Back to cited text no. 26
Belli R, Rahiotis C, Schubert EW, Baratieri LN, Petschelt A, Lohbauer U, et al. Wear and morphology of infiltrated white spot lesions. J Dent 2011;39:376-85.  Back to cited text no. 27

This article has been cited by
1 Comparative evaluation of esthetic improvement of resin infiltration and resin infiltration with double infiltrant application on nonpitted fluorosis stains: A six months prospective longitudinal study
Ishika Garg
SRM Journal of Research in Dental Sciences. 2021; 12(4): 192
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Clinical Charact...
Sites of Occurre...
Benefits of Earl...
Diagnosis and De...
Various Reminera...
Resin Infiltrati...

 Article Access Statistics
    PDF Downloaded505    
    Comments [Add]    
    Cited by others 1    

Recommend this journal